Jacob Vaughn Liljenquist, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

7754866-9921 Issued in UT

Practice address

1000 N 8TH Ave
Pocatello, ID 83201-5757

Phone

(208) 232-3368

Fax

(208) 776-5016

NPI assigned

Aug 20, 2010

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1282262400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1558051200000",
    "number": "1508172107",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9435 CASTLE OAKS DR",
            "city": "FOUNTAIN",
            "state": "CO",
            "postal_code": "808174517",
            "telephone_number": "702-426-7558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 N 8TH AVE",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832015757",
            "telephone_number": "208-232-3368",
            "fax_number": "208-776-5016"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LILJENQUIST",
        "first_name": "JACOB",
        "middle_name": "VAUGHN",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-08-20",
        "last_updated": "2019-05-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "UT",
            "license": "7754866-9921",
            "primary": true
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "UT",
            "license": "7754866-9921",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WA",
            "license": "DE60162914",
            "primary": false
        },
        {
            "code": "1223D0001X",
            "taxonomy_group": "",
            "desc": "Dentist, Dental Public Health",
            "state": "ID",
            "license": "D4811",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Life Design LLC
• Life, a Center for Independent Living
• Lifepoint Rehab Physician Services LLC
• Lighthouse for Recovery, LLC
• Dana F Liljenquist, D.C.
• Lily Pad Wellness, LLC
• Kelly Lind
• Lisa M Miller
• Larry Lisonbee
• Victor Liu, MD

• General Practice Dentistry in Pocatello, ID
• Providers in Pocatello, ID by specialty
• General Practice Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 17, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.